Consumer Focused Health

Thanks to the NYTimes, we now have another example of insurance companies dictating how care is to be delivered, through a one-size-fits all payment system: Aetna has decided that sedation is an unnecessary expense in the performance of colonoscopy.

Aetna, one of the nation’s largest private health plan managers, is the latest insurer to clamp down on the use of a powerful anesthetic during an increasingly common form of colon cancer screening.

The company will send a letter to doctors on Friday, saying that it plans to classify the drug as “medically unnecessary” for most such procedures. As of April 1, Aetna plans to stop paying for its use in those cases.

Now the major question is whether consumers are given the option to have sedation during colonoscopy or whether billing decisions now drive a race to the bottom in limiting choice. Whereas before, a doc might have pushed sedation without regards to the cost, now will they give the patient the choice of sedation at a reasonable cost? (e.g., through the use of balance billing and a menu).

There’s a relevant discussion from a previous post highlighting Mark Cuban’s experience with a colonoscopy.

Mark Cuban brings us an important public announcement to make sure you get your colonoscopy as suggested by the public health folks. On his blog he describes how most people tend to view the procedure:

Like every guy, the thought of being violated by a long tube is at the very bottom of the list of things I want to do on a summer day. I could live with having to take all the laxatives that lead up to the procedure, That’s just more time to get my reading done. But the tube up the outdoor, that’s scary.

I was definitely nervous. Despite doctors and nurses telling me it would be a breeze, I was naturally skeptical.

Now when it comes to his actual experience, he has quite a bit of a different experience than some of his readers:

A breeze was an overstatement. I can honestly say that if it made medical sense to get one done every year, i would have no problem with it. It was easy and breezy .

Once I got into the Gastro Room where they did these, they told me that they were going to knock me out, and I would get a nap and wake up like nothing happened . They were right. One minute Im talking rugby, the next I’m waking up, picking up the conversation where I left off and being told to “dispell the air in my system”.

Lucky for him this happened automatically. Some of his readers clearly had different takes on their non-option of getting knocked out for the procedure.

1. Okay, I’m pissed. Why is it they knocked you out, but my doctor wouldn’t knock me out? I had to remain conscious for the whole [expletive deleted] examination! And I gotta tell ya, it’s no picnic!!!

Damn, damn, damn, damn, DAMN!

Posted at 12:04PM on Jun 14th 2007 by emh

As we think about Aetna’s incentives, a sedated colonoscopy is likely to drive up cost indiscriminately, with sedation given to many more people than truly desired the service (vs. the extra expense). (We’ll hold off for now on the discussion of whether this is good or not for Aetna– it often differs based on contractual relationships with employers). The cost is really high, because GI docs have decided for the most part not to do the anesthesia themselves and bring much added expense in having an anesthesiologist present in the office (both huge added expense and likely subscale to maximize the use of the anesthesiologist).

In a consumer-focused world, how might this look? Instead, the consumer in evaluating colonoscopy options may look for sedation as an option and compare anesthesiologist delivered vs. GI doc delivered on cost and benefit. Where anesthesiologists delivered the meds, there might be a scaled colonoscopy facility that could spread the anesthesiologists time across multiple patients, and may even use a Nurse Anesthesiologist to extend care across even more. The cost for a sedated colonoscopy would plummet as the business model was refined and competition between colonoscopy options was transparent, especially in big cities. (Others may choose to use the pill camera as a substitute, creating a tiered market in terms of colonscopy intensity. This likely would raise colonoscopy rates, as there was a different option for all levels of concern, and pricing would be pegged off the cheapest options. Looks significantly different from today, doesn’t it? Its not a system that Aetna or the other big insurance payers will be able to deliver, so look for the emergence of these new systems as employers continue to retreat from comprehensive health insurance.